Musculoskeletal Agents:

Antirheumatic & Osteoporosis

Nova Southeastern University
Ron and Kathy Assaf College of Nursing
NUR 3192: Pharmacologic Basis
for Nursing Interventions II
 Rheumatoid Arthritis vs. Osteoarthritis
 Autoimmune disorder  Another type of arthritis
causing inflammation  Age-related degeneration
and tissue damage in of joint tissues
joints  Pain and reduced
 Diagnosis primarily function
symptomatic
 Treatment consists of
nonsteroidal
antiinflammatory drugs
(NSAIDs) and DMARDs

Rheumatoid Arthritis Osteoarthritis

 Disease-Modifying Antirheumatic Drugs
(DMARDs)
 Modify the disease of RA
 Exhibit antiinflammatory, antiarthritic, and

immunomodulating effects
 Inhibit the movement of various cells into an

inflamed, damaged area, such as a joint

 Slow onset of action of several weeks, versus

minutes to hours for NSAIDs

 Also referred to as slow-acting antirheumatic

drugs (SAARDs)
 DMARDs
 methotrexate  adalimumab (Humira)
 leflunomide  anakinra
 sulfasalazine
 etanercept (Enbrel)
 infliximab (Remicade)
 hydroxychloroquine  adalimumab
 Abatacept (Orencia)
 rituximab
 tocilizumab (Actemra)
 tofacitinib (Xeljanz)

Traditional/Nonbiologic Biologic Agents

 DMARDs
 DMARDs provide anti-inflammatory and
analgesic effects and can arrest or slow disease
processes associated with RA

 Current recommendation of first-line therapy in

clients with RA
Methotrexate: Non-biologic DMARD
 Used as baseline therapy in most RA clients
 Typical dose 7.5-25 mg orally or injection once per week
 Labs:
◦ Hepatitis serologies
◦ LFTs
◦ CBC Prior to starting and then every 2-3 months
◦ Creatinine
 Adverse effects:
◦ Nausea, diarrhea, fatigue, mouth ulcers, rash, alopecia, pneumonitis,
sepsis, liver disease, Epstein-Barr virus-related lymphoma
 Must be taken with folic acid supplements
 May take 3-6 weeks to see onset of antirheumatic action
Leflunomide: Non-biologic DMARD
 Treatment of active RA
 Modulates or alters the responses of the immune

system to RA
 Antiproliferative, antiinflammatory, and

immunosuppressive activity
 Adverse effects: diarrhea, respiratory tract

infection, alopecia, elevated liver enzymes, rash

 Contraindicated in women who are or may

become pregnant
 Biologic DMARDs: Can be administered in
combination with methotrexate
 Caution if the patient has a  Erelzi is the approved
history of recurrent infections biosimilar product for
or chronic obstructive etanercept.
pulmonary disease  Patients must be screened for
 Patients must be up to date on latex allergy (some dosage
immunizations before starting forms may contain latex).
therapy.  Onset of action: 1 to 2 weeks
 May increase risk of infections
 Contraindicated in presence of
associated with live vaccines active infections
◦ Reactivation of hepatitis and
 May decrease response to
tuberculosis has been reported
vaccines

Abatacept Etanercept
 Nursing Implications
 Assess for allergies, specifically allergies to egg
proteins, IgG, or neomycin
 Assess for conditions that may be

contraindications
 Assess baseline blood counts; perform cardiac,

renal, and liver studies

 Assess for presence of infection
 Follow specific guidelines for preparation and

administration of drugs
 Monitor the client’s response during therapy
Nursing Implications (cont’d)
 Teach clients to report signs of infection
immediately
◦ Sore throat
◦ Vomiting/diarrhea
◦ Fever over 100.5°F (38.1°C) or higher
 Monitor for therapeutic responses
◦ Decrease in growth of lesion or mass
◦ Improved blood counts
◦ Absence of infection, anemia, and hemorrhage
 Monitor for adverse effects
Osteoporosis
 Age-related degeneration
of joint tissues  pain
and reduced function
 Low bone mass 
increased risk of fractures
 Primarily affects women
◦ 40% of women over 50
years will develop
osteoporotic fracture
 20% with this condition
are men
Osteoporosis: Risk Factors
 European/Asian descent
 Slender body build
 Early estrogen deficiency
 Smoking
 Alcohol consumption
 Low-calcium diet
 Sedentary lifestyle
 Family history
 Drug Therapy for Osteoporosis
 Calcium supplements and  Bisphosphonates
vitamin D may be ◦ Alendronate,
recommended for women ibandronate, risedronate,
at high risk for zoledronic acid
osteoporosis  Selective estrogen
 Current recommendations
are that women, especially
receptor modifiers
those older than age 60, (SERMs)
consider taking calcium ◦ Raloxifene, tamoxifen
and vitamin D  Hormones
supplements for bone ◦ Calcitonin, teriparatide,
health denosumab
Bisphosphonates
 Work by inhibiting osteoclast-mediated bone resorption
 indirectly enhances bone mineral density 
preventing bone loss
 Can reverse lost bone mass and reduce fracture risk
 Prevention and treatment of osteoporosis and Paget’s
Disease
 Examples
◦ alendronate
◦ ibandronate
◦ risedronate
◦ zoledronic acid
 Bisphosphonates: Mechanism of Action
 Highly selective inhibitor of bone resorption
◦ Resorption occurs following activation of osteoclasts  to
breakdown bone and releases from bone to the blood
 Reduction in bone resorption  decreased serum
calcium & phosphate concentrations
 Increased bone mineral density to reverse

progression of osteoporosis
 Absorbed orally - decreased absorption by 40% if

taken with food & beverages (other than plain

water)
 Stored in skeleton (not metabolized after

absorption)  slow release  urinary excretion

 Bisphosphonates:
Contraindications & Interactions
 Drug hypersensitivity  Known drug interactions
 Hypocalcemia ◦ Ranitidine: doubles
bioavailability of
 Esophageal alendronate
dysfunction ◦ Calcium supplements &
antacids: separate doses by
 Inability to sit or 2 hours
stand upright for at ◦ Aspirin: increased risk of
GI effects
least 30 minutes after  Advise client to wait at
taking the medication least 30 minutes after
taking alendronate before
taking any other drug
Bisphosphonates: Adverse Effects
 Headache, GI upset, joint pain
 Risk of esophageal burns if medication lodges in

esophagus before reaching the stomach

◦ GI irritation more likely if client does not take with full
glass of water
 Risk of osteonecrosis of the jaw
 Possible severe (incapacitating) bone, joint, or

muscle pain
Alendronate
 Oral bisphosphonate
 First nonestrogen nonhormonal option for

preventing bone loss

 Inhibits or reverses osteoclast-mediated bone

resorption
 Indications: prevention and treatment of

osteoporosis in men and in postmenopausal

women as well as treatment of glucocorticoid-
induced osteoporosis in men and for the treatment
of Paget disease in women
 Bisphosphonates: Nursing Implications
 Ensure that patients have no esophageal
abnormalities and can remain upright or in a
sitting position for 30 minutes after the dose
 Instruct patients to take medication upon rising in

the morning, with a full glass of water, and

30 minutes before eating.
 Emphasize that patients should sit upright for at

least 30 minutes after taking the medication

Selective Estrogen Receptor Modifiers
(SERMs)
 Stimulate estrogen receptors on bone and increase
bone density
 Drugs

◦ raloxifene
◦ tamoxifen
 Indications
◦ Prevention of postmenopausal osteoporosis
 Stimulate estrogen receptors on bone and increase
bone density
SERMs: Contraindications
 Women with known allergy
 Women who may become pregnant
 Venous thromboembolic disorder or history

◦ Deep vein thrombosis (DVT)

◦ Pulmonary embolus (PE)
◦ Retinal vein thrombosis
SERMs: Adverse Effects
 Hot flashes
 Leg cramps
 Increase risk of venous thromboembolism
 Teratogenic
 Leukopenia
SERMs: Nursing Indications
 Instruct clients that the medication will need to be
discontinued 72 hours before and during any
prolonged immobility (such as surgery or a long
trip)
Hormones: Calcitonin
 Indications: treatment of osteoporosis
 Mechanism of actions: Directly inhibits

osteoclastic bone resorption

 Contraindications: drug allergy or salmon allergy
 Adverse effects

◦ Flushing of the face

◦ Nausea/diarrhea
◦ Reduced appetite
 Nasal spray most used
Hormones: teriparatide
 Mechanism of action: Stimulates bone formation
 Contraindications: drug allergy
 Adverse effects

◦ Chest pain
◦ Dizziness
◦ Hypercalcemia
◦ Nausea
◦ arthralgia
Hormones: denosumab
 Mechanism of action
◦ Blocks osteoclast activation  prevents bone resorption
by blocking osteoclast activation
 Given as a subcutaneous injection once every 6
months with daily calcium and vitamin D
 Contraindications

◦ Hypocalcemia
◦ Renal impairment or failure
◦ Infection
 Adverse effects: infections
Herbal Products: Soy
 Relief of menopausal symptoms, osteoporosis
prevention
 Estrasorb, applied as a lotion
 Adverse effects

◦ Nausea
◦ Diarrhea
◦ Abdominal pain
◦ Estrasorb remains on skin for 8 hours
Nursing Implications
 Assess baseline vital signs, weight, blood
glucose levels, and renal and liver function
study results.
 Assess whether the patient smokes.
 Assess history and medication history.
 Assess contraindications, including potential

pregnancy.
 Monitor for therapeutic responses.
 Monitor for adverse effects.
References
 Lilley, L. L., Rainforth Collins, S., & Snyder, J. S.
(2020). Pharmacology and the nursing process. (9th ed.)
Elsevier.
 Zerwekh, J., Garneau, A., & Miller, C. J. (2017). Digital
collection of memory notebooks of nursing (4th ed.).
Nursing Education Consultants.